Depending on the size, number and location of your fibroids, your surgeon may choose one of three surgical approaches to myomectomy.
In abdominal myomectomy (laparotomy), your surgeon makes an open abdominal incision to access your uterus and remove fibroids. Your surgeon enters the pelvic cavity through one of two incisions:
A horizontal bikini-line incision that runs about an inch (about 2.5 centimeters) above your pubic bone. This incision follows your natural skin lines, so it usually results in a thinner scar and causes less pain than a vertical incision does. It may be only 3 to 4 inches (8 to 10 centimeters), but may be much longer.
Because it limits the surgeon's access to your pelvic cavity, a bikini-line incision may not be appropriate if you have a large fibroid.
- A vertical incision that starts in the middle of your abdomen and extends from just below your navel to just above your pubic bone. This gives your surgeon greater access to your uterus than a horizontal incision does and it reduces bleeding. It's rarely used, unless your uterus is so big that it extends up past your navel.
Laparoscopic or robotic myomectomy
In laparoscopic or robotic myomectomy, minimally invasive procedures, your surgeon accesses and removes fibroids through several small abdominal incisions.
- Laparoscopic myomectomy. Your surgeon makes a small incision in or near your bellybutton. Then he or she inserts a laparoscope ― a narrow tube fitted with a camera ― into your abdomen. Your surgeon performs the surgery with instruments inserted through other small incisions in your abdominal wall.
- Robotic myomectomy. Instruments are inserted through small incisions similar to those in a laparoscopic myomectomy, and the surgeon controls movement of instruments from a separate console.
Sometimes, the fibroid is cut into pieces and removed through a small incision in the abdominal wall. Other times the fibroid is removed through a bigger incision in your abdomen so it can be removed without being cut into pieces. Rarely, the fibroid may be removed through an incision in your vagina (colpotomy).
Laparoscopic and robotic surgery use smaller incisions than a myomectomy, or laparotomy, does. This means you may have less pain, lose less blood and return to normal activities more quickly than with a laparotomy.
To treat fibroids that bulge significantly into your uterine cavity (submucosal fibroids), your surgeon may suggest a hysteroscopic myomectomy. Your surgeon accesses and removes fibroids using instruments inserted through your vagina and cervix into your uterus.
A hysteroscopic myomectomy generally follows this process:
- Your surgeon inserts a small, lighted instrument — called a resectoscope because it cuts (resects) tissue using electricity or a laser beam — through your vagina and cervix and into your uterus.
- A clear liquid, usually a sterile salt solution, is inserted into your uterus to expand your uterine cavity and allow examination of the uterine walls.
- Using the resectoscope, your surgeon shaves pieces from the fibroid until it aligns with the surface of your uterine cavity.
- The removed fibroid tissue washes out with the clear liquid that's used to expand your uterus during the procedure.
Rarely, your surgeon may use a laparoscope inserted through a small incision in your abdomen to view the pelvic organs and monitor the outside of the uterus during a complicated hysteroscopic myomectomy.
After the procedure
At discharge from the hospital, your doctor prescribes oral pain medication, tells you how to care for yourself, and discusses restrictions on your diet and activities. You can expect some vaginal spotting or staining for a few days up to six weeks, depending on the type of procedure you've had.